Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Patient choice?
- Michael P Williams (26 August 2006)
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Exempt patients from smoking bans when acutely mentally unwell
- T Everett Julyan (29 August 2006)
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Exempting mental health units from smoke-free laws
- Anthony J Williams (29 August 2006)
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Exempting mental health units from smoke-free laws should no longer be ignored
- Faouzi Dib Alam (31 August 2006)
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Smoking on Acute Mental Health Units
- Cyrus Abbasian, Mariwan Husni, Consultant Psychiatrist, Northwick Park Hospital, HA1 3UJ (31 August 2006)
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Let us be honest and ask for a tobacco ban
- Christopher R Clark, Bernadette A. McInerney, Consultant Forensic Psychiatrist, Rampton Hospital (31 August 2006)
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Smoking subculture in psychiatric patients
- Daniel Tai-yin Tsoi (1 September 2006)
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Re: Smoking on Acute Mental Health Units
- Rosemary Slosek (1 September 2006)
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Smoking, readiness and informed consent
- Patrizia Fiorillo, NSW 1670 (1 September 2006)
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"Non-patchers"
- Phillip J. Colquitt (2 September 2006)
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Mental health units should be exempt from smoke free laws.
- helen c teare (10 September 2006)
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Risks of "passivity smoking"
- Michael J Smith (11 September 2006)
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Exempting mental health units from smoke-free laws; response to editorial correspondence
- Jonathan Campion, Ann McNeill, Ken Checinski (27 September 2006)
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Michael P Williams, Consultant Radiologist Plymouth Hospitals NHS Trust
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I write as a doctor, an ex-smoker and one who has had admissions to a mental health unit. Surely to insist that mental health patients must suffer nicotine withdrawal at the time of major mental stress is unnecessarily cruel. The provision of smoking areas in mental health units means that only those who choose run the risks,such as they are,of passive smoking. There is also the little reported but, at least to patients, well known fact that smoking alleviates some of the painful, unpleasant, Parkinsonian side-effects common to many neuroleptic drugs which are not adequately treated by the standard medications procyclidine or benzhexol. By all means target mental health patients as a high risk group in need of smoking cessation assistance when they are well as outpatients but please do not add to their distress when they are at their most vulnerable and unwell as inpatients. Competing interests: Potential mental health inpatient |
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T Everett Julyan, SpR in Psychiatry Crosshouse Hospital, Ayrshire KA2 0BE
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EDITOR⎯ Campion et al. argue persuasively that psychiatric units should not be exempt from smoking bans(1). Their motives in being concerned for the physical health of mentally disordered patients are laudable but there are a number of issues which they do not discuss. Firstly, there are clinical issues. Nicotine can have beneficial effects on mood, anxiety and cognition, and ameliorates some of the side- effects of psychotropic medication. In contrast to this, acute nicotine withdrawal can exacerbate psychiatric symptoms and cause diagnostic difficulty. Cigarette smoke also induces the metabolism of many different psychotropic drugs(2). Therefore, enforcing acute smoking cessation in mentally unwell patients may cause significant problems, including making the patient feel worse, clouding the clinical picture, worsening the side- effects of prescribed medication and precipitating drug toxicity. When the patient starts smoking again post-discharge, there is an increased risk of relapse (secondary to re-stimulation of their hepatic microsomal enzyme system and associated reduction in plasma levels of their prescribed medication). Secondly, there are ethical and legal considerations. It may be considered acceptable to enforce a smoking ban on patients who are free to leave hospital and who stay of their own volition. However, it does not seem reasonable to enforce this on patients who are detained against their will under mental health legislation, especially in Scotland where the principles of least restrictive alternative and reciprocity are recognised(3). Thirdly, there is pragmatism. Even in studies where motivated patients use smoking cessation aids in the absence of acute mental illness, it is only the minority who remain abstinent in the medium to long term. Is there any clear evidence that enforcing a blanket smoking ban on acutely unwell psychiatric patients will result in longer-term benefit for them in the real world? I would love to live and work in a smoke-free environment. However, I remain unconvinced that we are treating patients as we ourselves would wish to be treated if we ban them from smoking against their will when mentally ill. It is one thing to help smokers give up when they are well enough to make an informed choice for themselves. It is quite another to enforce a smoking ban on acutely unwell patients. (1) Campion J, McNeill A, Checinski K. Exempting mental health units from smoke-free laws. BMJ 2006;333:407-408. (26th August.) (2) Taylor D, Paton C, Kerwin R. The Maudsley 2005-2006 Prescribing Guidelines (8th Edition). London: Taylor & Francis. (3) The Scottish Parliament. Mental Health (Care & Treatment) (Scotland) Act 2003. http://www.opsi.gov.uk/legislation/scotland/acts2003/20030013.htm Competing interests: None declared |
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Anthony J Williams, Mental Health Act Commissioner & retired Consultant Psychiatrist Cardiff CF14 6QR
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Editor-The editorial by Campion, McNeil and Checinski misses some of the complexities of the issue when they suggest psychiatric institutions in England and Wales should not be exempt from the Health Act 2006 and that all mental health settings should introduce smoke-free policies (1). Patients admitted to psychiatric units are invariably in a state of crisis and mental turmoil and at such times to be obliged to stop smoking would seem inappropriate and non-therapeutic. Naturally, if the patient wants help with stopping smoking at that time it should be offered as part of the treatment plan. The case of a patient who is detained under the Mental Health Act is further complicated. This patient is being detained in hospital against his will and very likely receiving treatment to which he has not consented. Not only will he be deprived of his liberty but forced, by the circumstances of being detained in hospital, to stop smoking. To compel a patient to stop smoking would unlikely to be a lawful use of the powers of the Mental Health Act and to enforce a ban on smoking could be found to be an unjustifiable interference with his human rights if it were subject to a legal challenge(2). Of course, if a detained patient wants treatment to stop smoking this should be made available. The Government policy is not to give mental health units a complete exemption from smoke-free legislation but that patient would be allowed exemption on a case by case basis. It would not be workable to apply this to detained but not to non-detained patients. It would seem appropriate that in the future mental health units should provide a smoking facility for patients who need to be in hospital, because of their mental disorder, but at the same time do not wish to stop smoking. These facilities should be provided in such a way as to minimise the nuisance and risk of passive smoking to other patients and to staff. References 1.Campion J, McNeil A ,Checinski K. Exempting mental health units from smoke-free laws. B.M.J. 26 August 2006 2.Mental Health Act Commission. Policy Briefing For Commissioners. August 2006 Competing interests: None declared |
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Faouzi Dib Alam, Specialist Registrar Royal Preston Hospital, Sharoe Green Lane, Preston, PR2 9HT
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I read with interest the paper by Campion et al (2006) on exempting mental health units from smoke-free laws. I believe that the government, by allowing smoking in psychiatric units, will only increase stigma towards psychiatric patients in a time the royal college of psychiatrists is trying hard to reduce it. It has been argued that hospitalization of smokers with mental illness in smoke-free psychiatric units may lead to behavioural deterioration, but I will present some evidence which refutes this argument. In 1987, the Board of Trustees of Southwest Washington Hospitals (USA) instituted a smoking ban in all of its facilities, including general psychiatry unit. The changes were introduced successfully with minimal impact on the successful function of the psychiatric service (Thorward et al 1989). More so in 1994 Ryabik et al reported that implementation of a smoking ban, establishing a smoke-free psychiatric service and abolishing tobacco products created minor management difficulties on a locked psychiatric unit (Ryabik BM et al,1994). The effects of prohibiting cigarette smoking on the behavior of patients on a 25-bed psychiatric inpatient unit were assessed immediately after implementation of a smoking ban in the USA and two years later. No major behavioral disruptions were observed after the ban. The number of calls for security assistance, physical assaults, instances of leather restraints and of seclusions, and discharges against medical advice did not increase significantly immediately after the restriction on smoking or two years later (Velasco et al 1996). Signs and symptoms of nicotine withdrawal and alterations in psychopathology were evaluated among acutely ill psychiatric patients admitted to a hospital with a smoking ban. Despite subjects' reports of feeling distressed and of experiencing nicotine withdrawal symptoms, abrupt cessation of smoking did not significantly affect either the severity or the improvement of psychopathological symptoms during hospitalization. The authors concluded that no compelling reasons to reverse the smoking ban were observed (Cedric M 1999). In the current climate of growing concern for the harmful effects of cigarette smoking and passive smoking and with supporting evidence for smoking ban, exempting mental health units from smoke-free laws can no longer be ignored. Velasco, J., Eells, T.D., Anderson, R. et al. A two year folloe up on the effects of smoking ban in an inpatient psychiatric service. Psychiatr Serv 1996;47 (8): 869-871. Cedric M. Smith, M.D., Cynthia A. Pristach, M.D. and Maria Cartagena, M.D. Obligatory Cessation of Smoking by Psychiatric Inpatients Psychiatric services. APA 50:91-94, January 1999. Thorward, S.R., Birnbaum,. Effects of a smoking ban on a general hospital psychiatric unit. Gen Hosp Psychiatry.1989 Jan;11(1):63-7. Ryabik, B.M., Lippmann, S.B., Mount,R., Implementation of a smoking ban on a locked psychiatric unit. Gen Hosp Psychiatry. 1994 May;16(3):200-4. Competing interests: None declared |
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Cyrus Abbasian, Specialist Registrar in Psychiatry St Thomas' Hospital, London, SE1 7EH, Mariwan Husni, Consultant Psychiatrist, Northwick Park Hospital, HA1 3UJ
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EDITOR – Campion et al raises important issues regarding tobacco consumption on psychiatric units, problems this can lead to in a highly vulnerable group of patients, and the urgency with which smoking cessation programmes in mental health settings are required (1). It is known that psychiatric patients smoke at much higher levels than the non-mentally ill populations, and also derive additional nicotine by – for example - taking extra puffs and inhaling deeper. However Campion et al, in their editorial, fail to raise a number of important issues, most notably that patients with Schizophrenia smoke cigarettes for different reasons than the normal population. Recent genetic linkage studies show evidence of nicotinic receptor alpha-7 subunit involvement in both smoking and schizophrenia (2). Further, most research on nicotine cessation interventions – including Nicotine Replacement Therapies – are carried out on non-mentally ill populations and lack generalisability in the mental health settings (3). At the most recent American Psychiatric Association Conference in Toronto a symposium was dedicated to Nicotine Dependence and Schizophrenia (4). Sensory gating deficits in Schizophrenia - which can be normalised by nicotine - was raised as one possible cause for the high prevalence of smoking in this population. These patients also tend to have reduced nicotinic acetylcholine receptors, and nicotine may in fact be a form of self-medication due its cognitive enhancing properties. Abstinence rate amongst smokers with Schizophrenia was researched to be virtually nil without intervention, and short-term rates of l0-40% were achieved with nicotine replacement and psychosocial strategies. The symposium concluded that the treatment of tobacco dependence in Schizophrenia requires long- term strategies, combination of medication with psychosocial interventions, and integration into the overall patient management with the aim relapse prevention. In absence of robust evidence based policies tailor made for specific psychiatric diagnosis, and trained psychiatric staff to deliver these, an enforced blanket ban on smoking is likely to be counter productive. It could for example force patients to smoke discretely – and hazardously - on psychiatric units. Under the circumstances, the proposed exemption for units where inpatients are admitted for less than six months is an acceptable strategy, as perhaps it could focus scarce resources on rehabilitation settings. A more simple solution at present could lye with making designated smoking areas unattractive, so they are no longer the social hub of acute mental health units, as they remain in some institutions. References: 1. Campion J, McNeill A, Checinski K. Exempting mental health units from smoke-free laws. BMJ 2006; 333:407-408 (26 August) 2. Ripoll N, Bronnec M, Bourin M. Nicotinic receptors and schizophrenia. Current Medical Research & Opinion. 20(7):1057-74, July 2004. 3. The Medical Clinics of North America 88(6), November 2004. 4. American Psychiatric Association Conference 2006. Symposium number 81 (24 May). Abstracts access via: http://www.sessions2view.com/apa_library Competing interests: None declared |
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Christopher R Clark, Consultant Forensic Psychiatrist Rampton Hospital, Nottinghamshire Healthcare NHS Trust, Retford, Notts. DN22 0PD, Bernadette A. McInerney, Consultant Forensic Psychiatrist, Rampton Hospital
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Campion et al (Editorial 26 August) raise some important points about detained patients and smoking, but miss a fundamental one. Patients detained under the Mental Health Act cannot go home to smoke as everyone else will be able to under new legislation. Therefore a smoking ban means that they will have no access to tobacco at all, unlike the rest of the population. However beneficial, this is surely unfair. If it is argued that detained patients should be treated in this manner then fairness demands that access to tobacco should be banned for all. On health grounds this is the logical position, not the position suggested in the editorial; the total banning of smoking in psychiatric institutions. There can then be a debate about whether this is acceptable in terms of governmental interference with personal freedom. In making this argument for a different view I do not underestimate the degree of harm caused to patients in psychiatric hospitals caused by their smoking. As Campion points out, it is very considerable and, until tobacco is banned for everyone, robust policies need to be in place to reduce it. Competing interests: None declared |
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Daniel Tai-yin Tsoi, Clinical Lecturer in Psychiatry Academic Clinical Psychiatry, Longley Centre, Norwood Grange Drive, Sheffield S5 7JT
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Editor,
Campion, McNeill & Chencinski raise their concerns about further worsening of health inequalities for people with mental health problems if smoke-free laws are exempted in mental health units (1). However, the relationship between smoking ban and health equality is not a straight forward one and there are a number of issues which need to be considered. Heavy smoking is related to a perception of powerlessness and futility in the daily lives (2) and these are common experiences among individuals with mental health problems. Tobacco is viewed as a “chemical comforter” helping them to cope and maybe one of the ways to reduce the possible distress from the symptoms. Hospitalisation is already reinforcing the sense of powerlessness, especially for those detained under the Mental Health Act. Smoking ban in in-patient units, particularly in acute wards, is likely to exaggerate this feeling. There is a possibility that patients refuse to come to hospital informally because of the smoking ban, even in-patient treatment is the best option for them. As a result of this, patients may need to be detained under the Mental Health Act. Psychiatric treatment has changed dramatically in the past decades, with an increased emphasis on treatment in the community and the view of service users. One of the reasons for this shift is to allow individuals with mental health problems to be managed in a less restrictive environment. This has shown to improve patients’ satisfaction (3). Without doubt, in-patient psychiatric treatment is still needed for more disturbed patients. Even so, these patients should be managed in an environment with minimal restriction if possible. Complete smoking ban in psychiatric units instead of providing alternative ways (e.g. well-ventilated smoking room) can be viewed as coercion (4) and possibly counter-therapeutic. Even complete smoking ban in psychiatric units is endorsed, the attitude of staff in psychiatric unit is the key for successful implementation. A recent survey conducted in the UK has reported that nearly one in three psychiatric staff was against smoking ban in psychiatric settings (5). Nurses who felt mandated to enforce smoking bans believed this activity disrupted their relationships with patients and viewed tobacco control as a burden, even they clearly demonstrated knowledge of health consequences related to tobacco use (6). Present evidence also suggests that most of the patients resumed smoking after they were discharged from smoke-free psychiatric unit (7). One of the aims of smoke-free units is to encourage cessation. In order to achieve this goal, a more structured longer term intervention should be available. The NICE recommends brief intervention for smokers (8) in a recently published public health intervention guidance but it is still too early to know how well the guideline is followed, especially among individuals with mental health problems. Personally I do not smoke and I am more than happy to work in a smoke-free environment. However, with the current situation, complete smoking ban is likely to cause more problems rather than helping our patients to give up this addiction. Most researches focus on the pharmacological aspects of smoking in those with mental health problems. Ethnographic study exploring the meaning of this smoking subculture in individuals with psychiatric disorders may help to identify more suitable interventions for this group. References (1) Campion J, McNeill A, Checinski K. Exempting mental health units from smoke-free laws. BMJ 2006; 333: 407-408. (2) Helman C. Culture, Health and Illness. London: Butterworth Heinemann, 2000. (3) Johnson S, Nolan F, Pilling S, Sandor A, Hoult J, McKenzie N, White I, Thompson M, Bebbington P. Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study. BMJ 2005; 331: 559. (4) House of Commons health select committee. Smoking in public places. First report of session 2005-6. London: House of Commons, December 2005. (5) McNally L, Oyefeso A, Annan J, Perryman K, Bloor R, Freeman S, Wain B, Andrews H, Grimmer M, Crisp A, Oyebode D, Ghodse A. A survey of staff attitudes to smoking-related policy and intervention in psychiatric and general health care settings. Journal of Public Health 2006; 28: 192-196. (6) Schultz A, Bottorff J, Johnson J. An ethnographic study of tobacco control in hospital settings. Tobacco Control 2006; 15: 317-322. (7) Jonas J, Eagle J. Smoking patterns among patients discharged from a smoke-free in-patient unit. Hospital and Community Psychiatry 1991; 42: 636-637. (8) National Institute for Health and Clinical Excellence (NICE). Brief interventions and referral for smoking cessation in primary care and other settings. London: NICE, 2006. Competing interests: None declared |
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Rosemary Slosek, Graduate student University of Nottingham
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In my experience, making smoking areas on inpatient psychiatric units unattractive to discourage smoking would be ineffective. I worked on a major mental health crisis ward in Florida for 4 years. The smoking area was 2m x 4m furnished with rejected stained chairs and tables with bare concrete on 3 walls. The fourth side was a coarse metal screen since this smoking area was outside and open to the Florida heat, humidity and mosquitos. It was a very unpleasant place to be. It was also the busiest place on the ward and some patients would spend all their free time there from 5am til midnight. When we had a high census, you could smell tobacco smoke throughout the unit with all the doors closed. Competing interests: None declared |
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Patrizia Fiorillo, Nurse Manager Macquarie Hospital, NSW 1670
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I was very pleased to read Campion et al (2006) as the first article I found that considers the issues of smoking cessation, long-term hospitalization and the Mental Health Act. Some clarification is necessary, though, adding to the very cogent and comprehensive responses from other esteemed colleagues. I depart from a position as Nurses Manager in a large psychiatric institution where approximately 180 patients with chronic and enduring mental illness reside under the Mental Health Act and at the discretion of the Mental Health Review Tribunal. The NSW Health Policy Directive PO2005_375 [1] was welcomed and supported with open arms and this organization began looking at ways to facilitate smoking cessation amongst all the resident population. Overarching the smoking cessation plans is the Occupational Health and Safety requirement to provide a smoke-free environment and prevent exposure to passive smoking for those staff and patients who do not smoke. This hospital took the innovative stance of promoting and implementing smoke cessation practices across all 8 units (approximately 180 medium and long-stay patients) of which four are locked. Units kept documentary evidence of each patient’s smoking status and updated it regularly demonstrating a significant decrease in smoking within the chronic long-term population. There was however no data available demonstrating any challenges, risks, or misadventures resulting from neither the reduction nor the sudden cessation of smoking. All patients whose smoking habit was suddenly ceased on the grounds of severe physical impairment caused or exacerbated by smoking were reported as adjusting over time. Some were prescribed NRT patches. Overall the program was running very well and staff felt valued and useful in their caring role to ensure the overall health and wellbeing of this population. When I first started working here after 20 years in community care and crisis work, I became aware of smoking cessation practices that I found rather puzzling. Amongst these were the benevolent control of patient owned cigarettes without an assessment of that patient’s capacity to care for his/her own; a non-negotiable reduction to 15 cigarettes per day distributed at regular times, one-by-one; no assessment of dependence and withdrawal; no regular or consistent treatment of nicotine dependence; the restriction of smoking to a narrow time span over the day starting after breakfast; the withdrawal of cigarettes unless patients went to programs; the cutting of cigarettes by 1/3; the offering of PRN medication to patients who wanted a cigarette outside of regular times; the transfer of a small number of highly resistive patients with severe (lethal) smoke related conditions to locked units; and in a small number of unfortunate cases the restraining, sedating and secluding of patients whose determination to control their own choice (and right) to smoke led to extreme anger and confrontation with staff. The response sent by Faouzi Dib Alam [Exempting mental health units from smoke-free laws should no longer be ignored, 31st August 2006] summarises the current literature on the effect of smoking bans: they have had insignificant effects on the functioning of units; created minor management difficulties; there were no major behavioural disruptions; and did not significantly affect the severity or improvement of symptoms. However, no research has been conducted that measures a relationship between sudden cessation and levels of distress; feelings of powerlessness and intimidation; increased psychotic phenomena, depression or anxiety; requests for PRN medication (and/or offer from staff); patient experiences of stigma and discrimination; etc. The vulnerability to imposed practices by patient’s who have no choice in where they live and seldom have a voice in what happens to them. It is quite common for staff to interpret withdrawal symptoms as psychotic symptoms and treat them as such [2]. The association between hostility, dependence and withdrawal is clear [3-5] and aggression is recognized by patients and staff as a consequence of limit setting, rules and “controlling” measures and attitudes. [2,6]. The response by T. Everett Julyan [Exempt patients from smoking bans when acutely mentally unwell, 29th August 2006) is more to the point. Is this the way we would want to be treated? Would we impose these requirements on the many staff who smoke on campus (who smoke at all)? We have accepted THC (delta-9 tetrahydrocannabinol) as a therapeutic drug in cancer pain and glaucoma. We have learned a lot from the Prohibition days (and we know that today’s drinking laws have only taken alcohol to the homes). We allow palliative care patients to smoke and alcoholics to drive. Cigarettes, alcohol and junk food are supported by the government, are legal, and provide a hefty financial return. The health cost of smoking is enormous, no doubt. But the question begs: “What is driving us with people with mental illness?”. I will risk saying that it is a puritanical “do good” position that assumes people with a mental illness are not capable of looking after themselves and make choices “a reasonable person would make”; the view that psychiatry is responsible for the “whole” of the person with mental illness; that when under the Mental Health Act the person “has no rights”. However, people in the middle of a psychotic episode may be able to make decisions and give consent; reasonable people can and do make terrible decisions (smoke, drink, junk food, gamble …) and often give doubtful consent; and the Mental Health Act does not allow for decisions that are not related to treatment and containment of mental illness. If we were to consider smoking cessation as a medical intervention it would have to be an emergency before it would be approved by the Mental Health Review Tribunal or a guardian would need to be appointed. At this hospital we have considered all these questions, issues and ethical dilemmas. We have acknowledged that people with a mental illness have the same rights to success and failure as anyone else. We are now in the process of implementing a smoking cessation program that considers two priorities: protecting people from passive smoking and assessing readiness, voluntariness and informed consent to quit. We see smoking cessation with this vulnerable group as a medical intervention that requires care and close monitoring and we are committed to considering possible discharge plan and sustainability. There is no “them” and “us” until the legislation applies to ALL residential settings with all kinds of people, vulnerable or not, including our own homes as this is where our long-term patients are. When smoking becomes illegal total bans will make sense. [1] NSW Health (2005) Smoke free workplace policy – progression of the NSW Health, PD2005_375 [2] Duxbury, J. (2002) “An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: a pluralistic design,” Journal of Psychiatric and Mental Health Nursing, 9,325-337 [3] Fallon, J.H., Keator, D.B., Mbogori, J. and Potkin, S.G. (2004) “Hostility differentiates the brain metabolic effects of nicotine,” Cognitive Brain Research, 18(2),142-148 [4] File, S.E., Fluck, E. and Leahy, A. (2001) “Nicotine has calming effects on stress-induced mood changes in females, but enhances aggressive mood in males,” International Journal of Neuropsychopharmacology, 4(4),371 -376 [5] Cherek, D.R., Bennett, R.H. and Grabowski, J. (1991) Human aggressive responding during acute abstinence: effects of nicotine and placebo gum,” Psychopharmacology, 104(3),317-322 [6] Lawn, S. and Pols, R. (2003) “Nicotine withdrawal: pathway to aggression and assault in the locked psychiatric ward?” Australasian Psychiatry, 11(2),199-203 Competing interests: This response is my personal opinion |
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Phillip J. Colquitt, Technician/RN Independent Comment
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Co-workers in the mental health section here at Royal Brisbane and Women’s Hospital[RBWH] tell me they have, like the whole campus, gone smoke free since the directive to do so came into “force” – June 30 2006. It’s a good thing. The focus should be on the needs of “breathers”, who should not be referred to as “non-smokers”, since the lesser thing should not describe the better thing. Nicotine patches are being used effectively, as near as I can tell. Rejects from the campus, in the form of "non-patchers", some with IV poles, can occasionally be seen getting booked as they stray from the pavement surrounding the campus, back to within the official boundaries. It's nice to see the area with benches under the trees available again to breathers. Competing interests: None declared |
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helen c teare, salaried g.p. swindon, wiltshire.
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Editor – I believe that Campion et al (1) are wrong to oppose the exemption of mental health units from smoke – free laws. We know that giving up smoking is difficult and that even patients who are motivated to stop, and are supported by trained stop smoking counselors and medication have relatively low success rates. (2) As a G.P. I offer advice on smoking cessation to all my patients but I would never try to force someone who was mentally ill to stop smoking – I would offer them the opportunity to give up smoking when they were better. Smokers with a history of major depression have been found to be at increased risk of developing a new episode of depression for the next six months after quitting (3) so surely an enforced abstinence during a hospital admission cannot always be in the patient’s best interests? People with severe mental illness suffer in a way that is beyond the understanding of most of us and their priorities for the future may be different to ours. Psychiatric admission may be stigmatizing and traumatic and being forced to stop smoking could compound our patient’s distress when they most need our help and understanding. We can’t force patients with chronic obstructive pulmonary disease or cerebrovascular disease to stop smoking so why should we impose this on one of our most disempowered and vulnerable groups? I agree that health workers also have rights but doctors and nurses choose their profession and all occupations have risks. Our patients, however, do not choose to have their lives blown apart by mental illness or to be held under a section of the mental health act. How do mental health service users feel about these issues? It would be interesting to hear their views. 1.Campion J, McNeill A, Checinski K Exempting mental health units from smoke-free laws. BMJ volume 333 26 August 2006 2.Sharma Sat, Lertzman M Nicotine Addiction e medicine.com updated july 12 2006 3.Glassman AH , Lino SC, Fay Stetner MS et al. Smoking cessation and the course of major depression : a follow up study. Lancet 2001 ; 357: 1929 - 1932 Competing interests: None declared |
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Michael J Smith, Consultant Psychiatrist and Clinical Director Dykebar Hospital, Paisley, PA2 7DE, UK
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On 1st February 2006, smoking was banned in NHS Argyll & Clyde premises and grounds, almost 2 months before the implementation of new legislation creating smoke-free enclosed public places throughout Scotland (1). Mental Health services in Renfrewshire decided not to "opt out" of the ban on smoking that applied to the rest of the NHS (with the exception of some psychiatric long stay wards). As far as we know, we were therefore the first mental health service in Scotland, and possibly in the UK, to implement such a smoking ban. There was considerable resistance to this policy, and the correspondence in these pages reflects opinions expressed to us at that time. One senior manager wryly commented "I have never known so many doctors trying to get smoking *into* hospitals". Three facts determined our policy: 1. Environmental tobacco smoke is harmful to all who inhale it, and we have a clear responsibility to protect patients, staff and visitors from this risk 2. Ventilation systems and separate smoking areas are not effective in removing tobacco smoke from buildings (2) 3. Partial smoking bans are ineffective (3) We also noted that “almost half of smokers' most recent attempts to stop involved no previous planning, and unplanned quit attempts were more likely than planned ones to be successful" (4). This policy has widely been accepted, at least for the prohibition of smoking within buildings. Clinicians and managers might be interested to know that (contrary to some peoples’ expectations): • There hasn’t been a single assault on staff in relation to smoking cessation, despite widespread (and stigmatising) fears of violence prompted by nicotine withdrawal • People don’t leave inpatient treatment en masse because they can’t smoke • there has been a five-fold increase in take-up of nicotine replacement therapy for inpatients • Our wards smell fresh, and our service users are far more active both physically and socially than they were previously. Staff no longer return home from work to find their clothes smelling of smoke Smoking has become a damagingly ingrained part of "asylum culture". We need to ensure that services do not underestimate the capacity of service users to stop smoking, because of a stigmatising presumption that “psychiatric patients” are different in this regard to the rest of us. We are proud that service users and staff in Renfrewshire are in the vanguard of a major progressive change in Scottish society, rather than being dragged behind it. The problem for mental health services isn’t just exposure to passive smoking, but the more insidious “passivity smoking”- the stigmatising presumption that nothing can be done to prevent it. Our experience confirms findings in the international literature: smoking cessation can be implemented in mental health units. In fact, doing so was much easier to achieve than many of us had expected. (1) http://www.clearingtheairscotland.com/background/index.html (2) Leavell et al. BMJ 2006; 332 (7535): 227 (3) Tobacco Control 2004;13:180-185 (4) BMJ 2006; 332: 458-460 Competing interests: None declared |
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Jonathan Campion, Specialist Psychiatry Registrar Roehampton Community Mental Health Team, Queen Mary's Hospital, London SW15 5PN, Ann McNeill, Ken Checinski
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We thank all those who have responded to our recent BMJ Editorial "Exempting mental health units from smoke-free laws"(1). In response, we would like to make the following comments: A) Self-medication; smoking is a recognised drug dependence and a cigarette is the equivalent of the dirty syringe with the nicotine delivered in a toxic cocktail of around 4,000 other smoke constituents, 60 of which are known carcinogens. Nicotine replacement therapies are the least harmful nicotine delivery systems available of which there are now six different forms (gum, patch, nasal spray, inhalator, lozenge and the sublingual tablet) in varying strengths and flavours. If self-medication for nicotine is part of the reason why people with mental health problems have high levels of smoking, then it is important to realise that smoking a cigarette is the most deadly known form of nicotine delivery. B) Self reliance; empowerment can be enhanced by a smoking ban with some patients experiencing increased sense of self esteem and mastery following a ban(2). When a smoker learns how to cope with withdrawal symptoms with the aid of nicotine replacement and that their daily routine does not need to be structured around cigarettes, they are able to become more confident that they can manage without them. We agree that it is critically important that service users are consulted, involved and supported in the transition to smoke free settings. C) Exacerbation of mental illness after smoking cessation; there is no clear evidence that stopping smoking exacerbates psychotic illness(3). There are also no consistent reports that anxiety increases following the first week of abstinence and it is suggested that smoking is chronically anxiogenic rather than being anxiolytic(4). D) Smoking cessation and potential medication toxicity; there are links between smoking status and antipsychotic medication. Cigarette smoke induces the metabolism of a number of psychotropic medications which means that for some patients who have stopped smoking, although there is potential danger of medication toxicity in the short-term, lower doses of medication may be required in the longer term. The guidance referenced in the editorial recommends that quit attempts be monitored carefully with all relevant health professionals and care workers informed of the treatment being given. E) Smoking culture within mental health settings; the relationship between nursing staff, other health professionals and their patients is critically important(5). The smoking culture in mental health units was demonstrated in a recent survey showing that 54% of mental health staff believed that staff smoking with patients was of value creating therapeutic relationships(6). Staff were found to experience more difficulty with total bans since they continued to smoke during breaks(7). There is even a suggestion that some mental health patients enter mental health settings as non-smokers and emerge as smokers, due to the smoking culture that still exists(7,8). We believe that condoning or encouraging cigarette smoking in those with mental illness is unacceptable given the huge impact of smoking on health. The question of why nicotine dependence is treated differently from other drugs of misuse such as alcohol needs to be considered. Self-medication with alcohol is also claimed for psychiatric disorders but alcohol is not condoned or tolerated in mental health settings. The analogy with alcohol is not perfect but the NHS is in the position with smoking that it was with alcohol 15-20 years ago (for staff as well as patient attitudes and behaviour). F) Need for comprehensive smoking cessation support; research shows that a proportion of smokers within mental health units want help with stopping but are not being offered this help in a consistent way. They are therefore unlikely to be aware that the NHS stop smoking services can offer free and intensive support to smokers needing it. G) Human rights: the Human Rights Act only allows an individual freedom of choice to act when their actions do not endanger others. Non- smoking service users and staff should not be exposed to the dangers of passive smoking. The effects of environmental tobacco smoke on health are now accepted and under the Health and Safety at Work Act, employers have a legal duty to protect both patients and staff from environmental tobacco smoke. H) Research: more research is needed into both the reasons for the relatively high levels of smoking among mental health patients and how best to help them to stop. I) Evidence for successful smoke-free policy implementation; there are numerous examples showing clear evidence that implementation of a smoke-free policy is possible in mental health settings (1,7,9,10). Partial solutions like ventilation have been demonstrated not to eliminate tobacco smoke and are no longer acceptable in other public places which explains why the government is introducing the comprehensive smoke-free law. References: (1) Campion J, McNeill A, Checinski K. Exempting mental health units from smoke-free laws BMJ 2006;333:407-408 (2) Cooke, A. Maintaining a smoke-free psychiatric ward. Dimensions in Health Service 1991;68:14-15. (3) Smith CM, Pristach CA, Cartagena M. Obligatory cessation of smoking by psychiatric inpatients. Psychiatric Services 1999;50:91-4. (4) West R, Hajek P. What happens to anxiety levels on giving up smoking? Am J Psych 1997;154:1589-92 (5) McNally L, Oyefeso A, Annan J, Perryman K, Bloor R, Freeman S, Wain B, Andrews H, Grimmer M, Crisp A, Oyebode D, Ghodse A. A survey of staff attitudes to smoking-related policy and intervention in psychiatric and general health care settings. Journal of Public Health 2006;28:192- 196. (6) Stubbs J, Haw C, Garner L. Survey of staff attitudes to smoking in a large psychiatric hospital. Psychiatr Bull 2004;28:204-7. (7) Hempel AG, Kownacki R, Makin DH et al. Effect of a total smoking ban in a maximum security psychiatric hospital. Behavioral Science and the Law 2002;20:507-22. (8) Lawn SJ, Pols RG, Barber JG. Smoking and quitting: a qualitative study with community-living psychiatric clients. Social Science and Medicine 2002;54:93-104. (9) Smith MJ (letter) Risks of "passivity smoking" BMJ 2006;333/7565/407 (10) Alam FD (letter) Exempting mental health units form smoke-free units should no longer be ignored BMJ 2006;333:551-2. Competing interests: None declared |
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